Child 6
First Name
Last Name
Email
Phone
Child's Full Name
*
Birthday
*
Age
*
Services Needed
*
Preschool Program (ages 2-5) (Part time 8am -11 am)
TK-Kindergarten (Part time 8am -12pm)
Daycare after the AM preschool / TK-Kinder program
After school program for TK-Kinder & School age kids
Summer Program Preschool and School age
Days Of The Week Needed
*
Monday
Tuesday
Wednesday
Thursday
Friday
Schedule
*
Full Time
Part Time
Full-Time Schedule
Name of School Attending
Under doctor's care
*
Yes
No
Does the child take prescribed medications?
*
Yes
No
Medical Condition
Potty Trained?
*
Yes
No
How do your child/children get along with other children?
Does the child experience any particular challenges, fears, or requirements?
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